24 Months to 18 Years + PPPE (Pre-Participation Physical Exam)

Age

24 Month

Measure- Wt
ments
Length

HC
BMI%

Develop- Walks up and

ment:
down stairs
Normal
Throws/kicks ball
Pulls off clothes
2 word sentences
50% speech
understandable to
stranger

30 Months
Wt
Length

HC
BMI%

3 Year
Wt
Ht

BMI%
BP

Points to 6 body
parts
Uses 3-4 word
phrases
Speech
understandable
50% of time to
stranger
Knows correct
action for
animal/human
(man talks, bird
flies)
Jumps in place
Throws ball
overhand
Copies vertical
line
Puts on clothes
with help
Brushes teeth
with help

Jumps in place
Pedals tricycle
Copies circle
3-4 word sentences
Shares
75% speech
understandable to
stranger

Few self help

skills

4-5 Years
Wt
Ht

BMI%
BP

Hops, Skips
Dresses self
Copies square then
triangle
Knows colors
Tells stories
100% speech
understandable to
stranger

6-10 Years
Wt
Ht
Tanner
Stage

none

II

Breast bud
diameter
<areola
Breast

IV

diameter >
areola
Mounding
of areola

III
IV
v

Development
Red
Flags

Does not have 6

words
Unable to communicate needs

Does not
verbally
communicate
needs

Cannot draw a
person with 3 body
parts
Cannot give first
and last name
3
PPD
CV Hearing / Vision8
3
4
CV
Health P.E.D.S. PPD
4
Vision
D.V. Health P.E.D.S.
Constipation
Sleep Habits D.V.

Screening

Anemia 1
Lead 2
PPD 3

Anemia 1
Lead 2
PPD 3

CV Health4
M.C.H.A.T.
P.E.D.S.
D.V.

CV Health4
ASQ
D.V.

Immunizations

Influenza
HepA status

Influenza
Update as
needed

Influenza
HepA status

DtaP#5
IPV#4MMR #2
Influenza
Varicella#2
HepA status

Anticipatory
Guidance

Toilet training
Tantrums/
Discipline
Supervise at play
Socialization with
other children
ROR, give book
Limit TV

Support
independence,
offer choices
Set clear rules
& limits
Encourage
healthy meals/
exercise
Supervise safe
play & sharing
ROR, give book

Car Seat til 4

years
Playground/Pool
safety
Bike safety
Never follow
strangers
ROR, give book

Dental

Sippy-cup pitfalls
Adult brush/BID 10
Dental Varnish*
Refer if high risk

Dental Varnish*
Dental referral
Adult
brush/BID10

Dental Varnish*
Dental referral
Adult brush/BID 10

Nutrition
/Supplements

Choose menu,
don't let child dictate it
Juice/soda status

Healthy snacks
Choose menu
Juice/soda
status

Healthy snacks
Family meals
Family meals
Soda status
Juice/soda status

BMI%

Wt

PPPE
BP

BMI%

Ht

BP
MALES

Ht

PR

Vision

Adult

Age (Y)
W

Testes

mons only
Adult to
mid thigh

History: Have Pt/Parent fill out

medical history side of PPPE while
waiting for MD
Review med hx info with Pt/Parent
Nutrition/supplements
Ergogenic/Performance Enhancing
Substances
Recent
illness (esp. Mono)
Current
Medications
NOTE:
DICTATE ALL SCREENING
QUESTIONS NORMAL ON PPPE
FORM EXCEPT AS NOTED then
list abnormal

AA

9.96+-1.82
11.3+1.42
12.88 + 1.2

8.87+1.93 >2.5cm

11.8(9.8-14.2)

10.9 +
1.42

>3 cm

13.0(11.7-14.6)

>4 cm

14.3(12.6- 15.8)

5 cm

15.1 (12.9- 17)

12.9(10.4 15.3)
14.5(11.3-17.8)

Pubic Hair Age(Y)

Age (Y)
W

AA

none
Sl.
PIgmented.
mons, labia
Dark,
coarse on
mons
Adult, on

Key Visit Issues

Age(Y)

< 2cm

Pubic
Hair
I
II

Wt

FEMALES
Breast

III

11-18 Years

BMI%
BP

none
10.51 + 1.67

8.78 +
2.00

11.53 + 1.42

10.35+
1.42

Sl. Pigmented
base of phallus
or scrotus
Dark, coarse.
Base of phallus

12.2(10.7-13.8)
13.9(12.0-15.7)

Adult,
suprapublic

12.6(10.4-14.8)

14.8 (12.9 - 16.4)

Adult to mid
thigh

14.6(12.4-16.8)

15.1 (13.8 - 16.8)

Precocious

If signs of puberty White <7.8 years African

American <6 8

If signs of puberty < 9

years

Delayed

No signs of puberty >12.5 years or no menses by

16 or 4 years after puberty started

No signs of puberty >

14 years

Hearing / Vision 8
CV Health4
Enuresis
Constipation
Sleep Habits
D.V.

PPD3 Hearing / Vision 8

Hct/Hgb 7
Glucose6 HEADSS / GAPS
NOTE: Dictate WNL except as noted
Sleep Habits
PPD3
CV Health4/ Glucose 6
Yearly Chlamydia screen in sexually
active males, offer HIV
Yearly GC/ Chlamydia screen in
sexually active females, PAP11, offer HIV

Influenza
status
Varicella #2

Red Flags
Cardio/Respiratory Hx
Syncope/family HX early death
Neuro: seizure, concussion
Hx of injury that limited activity
Absence of paired organ
History of heat illness
Acute illness
Vision

HEADSS /

GAPS
NOTE: Dictate all normal except as
noted
Hgb 7
NOTE: see adolescent prompts for
general screening

Influenza
Catch Up

Booster seat til 8

yrs or 80 Ibs
Bike safety
Limit TV
Discuss anger
resolving conflicts
w/out violence
ROR, give book
Gun safety

HepA Hep B series

HepA status
Tdap
Varicella #2
Influenza
HPV for females
Meningococcal vaccine
HPV
Limit TV
Safe sex
Encourage reading
Drinking and driving, seat belt use
Assign chores
Acne
Gun safety
Future goals
Booster seat until 8 yrs or 80 Ibs
Family activities
Seat belts
Regular physical exercise
Family activities
Gun safety
Regular physical exercise
18 yo: open discussion re transition of
care

Dental home
Adult brush/BID10

Brushing 2x daily10
home

Brushing 2x daily10
Dental home
Mouth guards for sports

Anticipatory Guidance/Dental:
Usual adolescent general guidelines
Performance enhancing substances
Sleep habits
Mouth Guard

Healthy food choices/family meals

Body image
Folic Acid(0.4 mg/d) for all females
Calcium 1300 mg/day

Nutrition Supplements
Hydration Tips

Dental

Family meals
Balanced diet
Avoid excess fat, salt, sugar,
juices/soda

Exam Key Areas:

Vision
Cardiac-Listen in Standing and Supine
Positions
Hx of prior injury and current functional
status
Splenomegaly
Skin
Marfanoid Syndrome

Recommended dietary fluoride supplement schedule

Age

Fluoride concentration in community drinking water

<0.3 ppm

0.3 0.6 ppm

>0.6 ppm

6 mos 3 years

0.25 mg/day

none

None

3-6 years

0.50 mg/day

0.25 mg/day

None

6-16 years

1 mg/day

0/5 mg/day

None

Anemia - Test Hct/Hgb in all patients with Medicaid at 12 months. Other patients assess for risk factors: premature
infants, low birth weight infants, given cow's milk before 12 months, drink more than 24 oz. of milk a day. If Hct<33 or
Hgb<11, start 5mg/kg iron and recheck in one month. AAP(2007) recommends screen all infants at 12 mo.
2
Lead-Test all Medicaid patients at 12 and 24 months. Other patients screened based on risk factors: living in house built
before 1950, living in a house built before 1978 that has been recently renovated, sibling or playmate with lead poisoning.
3
PPD - Screen patient exposed to person with TB, immigration from endemic countries; use of illicit drugs or cocaine;
exposure to person that is homeless, institutionalized in prison or nursing home, migrant farm worker, HIV infected,
visiting in endemic area > 1 mo. Perform test every 2-3 years. Retest immigrants in 6-12 months.
4
CV Health - (AAP, 2008) Screen children: > 2 yr w/positive family hx of dyslipidemia or premature (<55 yo male, <65 yo
female) CVD; Whose family hx unknown; With CVD risk factors: overweight/obese(BMI > 85%); hypertension (BP> 95%);
cigarette smoking; D.M. (screening test= fasting lipid panel)
6
Glucose - Obtain fasting glucose every 2 years if overweight with BMI >85%ile plus 2 of the following: Family hx of Type
II DM. African-American, American-Indian, Hispanic, Asian, acanthosis nigricans, hypertension, PCOS, dyslipidemia.
7
Hct/Hgb in Menstruating Females - Perform one baseline screening. Do yearly screen for moderate heavy menses,
chronic weight loss, nutritional deficit (vegetarian), or strenuous athletic activity.
8
Hearing / Vision- Hearing: >20dB at 1000-4000Hz is abnormal. Repeat 1 month, and then refer.
Vision: >20/40 or two line difference between eyes is abnormal. Refer.
9
Fluoride - Supplement, if at risk for caries and if water fluoride deficient, or exclusively breastfed; be aware of overfluoridation if age < 8 yrs.
10
Brushing < 3 years; If at risk for caries fluorinated TP, if not at risk low fluoride TP. > 3 years: fluoridated TP for all

Risk for Caries

Medicaid, CHIP, uninsured
History of caries in sibs./parents
<2 years: bottle to bed(not H20)
>2 years: High Sugar Diet
11

Thin prep cytology, 3 years after debut, the q. o. year

2005 UNC Department of Pediatrics Revised July 2008

(Amount of toothpaste = smear or 1/2 chocolate chip)

*Dental Varnish - Apply on all patients with Medicaid/Health Choice every 2 months from tooth eruption to 41 months.